Provider Demographics
NPI:1134343999
Name:LASALLE, PAULETTE MARIA (RN CNP)
Entity type:Individual
Prefix:MS
First Name:PAULETTE
Middle Name:MARIA
Last Name:LASALLE
Suffix:
Gender:F
Credentials:RN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 HERITAGE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9Y2E6
Mailing Address - Country:CA
Mailing Address - Phone:519-733-3167
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704124035363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI24878Medicare UPIN
ON13980096Medicare ID - Type Unspecified